DEVELOPMENTAL HISTORY QUESTIONNAIRE

1 DEVELOPMENTAL HISTORY QUESTIONNAIRE All questions contained in this QUESTIONNAIRE are strictly confidential and will become part of your clinical record. DEMOGRAPHICS Client s Name: (Last, First): M F (mm/dd/yyyy): Name of Parents: Family Heritage: ( Canadian/Dutch/French) Marital Status: Single Partnered Married Separated Divorced Widowed Religious Beliefs: ( Catholic/Islam/Judaism) Family Doctor: REASON FOR REFERRAL Chief Complaint [These would be the current areas of concern]. Please check any that are appropriate: Behaviour Physical Aggression Impulsive type/reactive Pre-mediated Verbal Aggression Sexual Aggression Property Damage Inattentive Hyperactive Impulsive Defiant Social Skills Emotional Depressed Mood Suicidal Thoughts Quick Emotional Fluctuations Increased Agitation Sleep Changes Excessive Changes in Energy Appetite Changes/Eating Disorder Victim of Abuse Anxious Academic Reading Difficulties Spelling Difficulties Math Difficulties Writing Difficulties Speech Difficulties Reading comprehension difficulties Overall Poor Educational Progress Suspensions/expulsions Use of 1.

2 1 EA support in school Reasoning Poor Problem Solving Poor Assessment of Risky Behaviour Readiness Understands there is a problem and wants help Understands there is a problem and not overly interested in help Understands there is a problem and doesn t want help Doesn t understand that there is a problem Describe a HISTORY of the identified difficulties and any current stressors: PREVIOUS EVALUATIONS: Please check any that have occurred: Name of Family Doctor : When: Diagnosis: Name of Pediatrician: When: Diagnosis: Name of Psychiatrist: When: Diagnosis: Name of Psychologist: When: Diagnosis: Name of School Board Psychologist: When: Diagnosis: Other Service Provider: When: Diagnosis: Are there currently any other agencies involved in this client s care? Please check: Children s Aid Society Children s Mental Health Mental Health Clinic Private Therapist School Child & Youth Worker Counseling Services of Belleville Probation Court Proceedings Other If Involved may these agencies be contacted as part of providing care to this client?

3 Yes Obtain Receive/Release Information sheet No Please explain why If the child is involved with the Children s Aid Society Please identify: Date of apprehension: Wardship Status: Name of Children s Service Worker: Agency: HISTORY of Placement (reasons for changes) Prenatal Period (Conception to Birth) What was the mother s age at time of birth? How many weeks occurred before the mother knew she was pregnant? Before knowing about the pregnancy did the mother s lifestyle contain any of the following: The use of prescribed medication No Yes What type of medication and for what reason? The use of nicotine No Yes If yes, how much was being used? The use of alcohol No Yes What type and how much was being used? The use of illicit drugs No Yes What type and how much was being used? Experienced periods of high stress from relationships, work, community, finances or partner abuse No Yes If yes, please explain Was the birth of this child Planned Unplanned Comment: Was the birth of this child Wanted by both Parents Unwanted by either Parent Unwanted, accepted by mother father Comment: What was the extended family s view of the pregnancy?

4 Check all that apply. Happy Supportive Concerned Unsupportive Other: How did the mother feel physically during the pregnancy? Did the mother experience any physical or emotional distress during the pregnancy? No Yes Please comment of type of physical, or emotional distress Did the mother have healthy eating patterns? No - If no, please explain Yes Did the mother take folic acid supplements? No Yes Did the mother take iron supplements? No Yes Did the mother experience any viruses or infections during the pregnancy? No Yes If yes when and what type Did the mother engage with assistant prenatal care and follow through with one doctor? No Yes If no describe Were any prescribed medications taken during the pregnancy? No Yes - What type of medication and the reason Did the mother smoke during pregnancy? No Yes - When and how much was used. Any drugs or alcohol taken during the pregnancy? No Yes - When, how much and what type was used Was the baby born full term?

5 (between 38 and 42 weeks) 40 +/- 2weeks No - Yes Please note either premature, or overdue and by how many weeks Were there complications during the delivery/ How was the labor process? ex.: non-surgical interventions, forceps, caesarians section No Yes - If yes, please comment: Check all that apply Short Long Easy Difficult How much did the baby weigh at birth? _____ lbs _____ oz or _____ grams Apgars scores if known _____ Did the baby require medical care resulting in separation from the parents? No Yes If yes, what type of care and for how long: Infancy (Birth to 2 years) How would you describe the emotional climate of the home when the baby arrived? Positive Concerned Negative Comment Who was the primary caregiver? Mother Father Mother and Father Other Please list other caregivers Mother Father Mother and Father Other Was the baby recalled to be a good eater, or fussy eater? Good eater Fussy Eater Comment Was the baby breast fed, or bottle fed?

6 Breast Bottle Comment How Long? Any reason why breast or bottle feeding was chosen? What were the babies early sleeping habits? Good Sleeper Poor Sleeper Comments: Was the baby cuddly ? No Yes Comments Was the baby comfortable with expressing and receiving affection? No Yes Comments What was the baby s energy level? Low Average High Comments Did the baby enjoy exploring the environment? No Yes Comments Was there anything that the baby appeared to find over-stimulating? ( noise, clothing, people) No Yes Comments Do you think that your baby began to sit, stand, walk, talk unusually late or early? (if unsure give best number in months). Low Average High Comments: Were there periods of high stress for the family in the first two years of life? No Yes - If yes, please describe the stress. Was there any separation between child and mother during the first two years of life? No Yes. If yes, please describe why and how old the child was Was there any separation between child and father during the first two years of life?

7 No Yes. If yes, please describe why and how old the child was When hurt, scared, or sick what was the child s typical reaction? Calm down by their self Cry Yell in the spot where the situation happened Seek their mother Seek their father Comments Who was considered the primary parent for the child? Mother Father Other Childhood (age 3 11) Toilet training At what age did the use of diapers stop during the days? At what age did the use of diapers stop during the night? At what age did learning to tie shoes occur? At what age did riding a bike occur? Has your child ever been seriously ill? If so what was the illness, age of onset and treatment. No Yes Comments Any sensitivity to certain foods? No Yes Comments Any allergies? If so, to what and how was it treated. No Yes Comments Has your child had any serious accidents or head injuries or seizures? No Yes Comments Describe temper tantrums. Any difficulties with speech?

8 No Yes Comments Any phobias? (Unusual fears?) No Yes Comments Any unresolved phobias (unusual fears) by age 10? No Yes Comments Any unusual motor or vocal sounds? (Tics?) No Yes Comments Please comment on the following areas associated with childhood temperament Activity: Activity refers to the child s physical energy. Please comment Regularity: Regularity, also known as Rhythmicity, refers to the level of predictability in a child s biological functions, such as waking, becoming tired, hunger, and bowel movement. Please comment Initial reaction: Initial reaction is also known as Approach or Withdrawal. This refers to how the child responds (whether positively or negatively) to new people or environments. Please comment Adaptability: Adaptability refers to how long it takes the child to adjust to change over time (as opposed to an initial reaction). Please comment Intensity: Intensity refers to the energy level of a positive or negative response.

9 Does the child react intensely to a situation, or does the child respond in a calm and quiet manner? Please comment A more intense child may jump up and down screaming with excitement, whereas a mild mannered child may smile Mood: Mood refers to the child s general tendency towards a happy or unhappy demeanor. Please comment Distractibility: Distractibility refers to the child s tendency to be sidetracked by other things going on around them. Please comment Persistence and attention span: Persistence and attention span refer to the child s length of time on a task and ability to stay with the task through frustrations. Please comment Sensitivity: Sensitivity refers to how easily a child is disturbed by changes in the environment. This is also called sensory threshold or threshold of responsiveness. Is the child bothered by external stimuli like noises, textures, or lights, or does the child seem to ignore them. Please comment How would you describe the mother and fathers parenting style?

10 Mother Passive Assertive Demanding Aggressive Other: Father Passive Assertive Demanding Aggressive Other: What was the child s reaction to discipline like? Accepting Passive Defiant Aggressive Other Any tendencies for the child to be excessively independent or dependent? Dependent Independent Mix Did the family experience periods of high stress during the childhood period? No Yes. If yes, what type of stress and what was the child s reaction to the stress Was there any disruption in the parental relationship by separation, or divorce? Was the child exposed to any form of domestic violence? No Yes If yes, please comment: During childhood where any of these features present (Please check all that apply) Excessive Clingy Periods of being unresponsive Inability to self-sooth Seeking comfort and then aggressive behaviour Inability to deal with stress/separation Was medical or clinical assistance provided to help development during childhood?